Lansing Clinic New Patient Request

Pease complete the form below to provide the authorization for Amberwell Health to obtain your medical records from your previous provider.

Date

Previous provider name*

Previous clinic name (if applicable)

Provider/Clinic Address*

Street Address

Address 2

CityState

Zip

Current Provider Phone Number*

Please enter a valid phone number.

Current Provider Fax Number*

Please enter a valid phone number.

Purpose of disclosure (select one)*

continuation of carechange of physician or providerOther

What level of records access are you authorizing?*

all medical recordsspecific medical records

What specific records are you authorizing?*

What date range are you authorizing?*

all available datesspecific date range

Please indicate the date range you are authorizing:

From*

Date

To*

Date

Driver's license or government issued ID#*

Upload photo of driver's license or government issued ID *

Expiration date (if desired)

Desired Expiration Date (if left blank authorization will expire 12 months from the date on which authorization was given)

Sign here*

Medical Records Release Authorization